Serbia rebuilds and reforms its health-care system

Abstract

When Snežana Simic joined the Republic of Serbia’s Ministry of Health in 2002, she looked forward to putting into practice what she taught her students as professor of public health at the School of Medicine, Belgrade University. “I knew all the concepts and all the advantages and disadvantages of the diff erent approaches”, Simic said in a recent interview in her offi ces in the Ministry of Health. “I wanted to see what worked.” At the time, Serbia had weathered more than a decade of political and economic turmoil. Shortly after the 1989 election of the ultranationalist Serbian leader Slobodan Milosevic, Yugoslavia broke up. The subsequent years were marked by political and economic chaos, ethnic strife and civil war, United Nations (UN) sanctions and international isolation, and, fi nally, a punishing 6-week North Atlantic Treaty Organisation (NATO) bombing campaign in 1999. The country is far from recovered. Not including Kosovo, which remains under UN administration, Serbia’s population of 7·4 million still includes 300 000 refugees and 220 000 internally displaced people. About 20% of Serbians live on less than US$90 a month, with 10% on less than $70 a month. Surprisingly, many health indicators seem to have improved or held steady during the 1990s. But assessing the true state of health in Serbia is diffi cult, says Simic, because data collection over the past decade has been patchy at best. Her impression, however, is that there has been an overall decline in the nation’s health. Today, the leading causes of death are heart disease, stroke, and cancer. Smoking alone is thought to cause 30% of deaths in Serbia, which is not unexpected in a country where half the men and a third of women smoke. On paper, Serbia seems to have a relatively good health system with a well developed network of primary, secondary, and tertiary care centres, Simic says. “Formally, you could say we had everything.” But the system was ineffi cient and underfunded; equipment and facilities were out of date; and the staff were underpaid and demoralised. A 2002 European Agency for Reconstruction study found that only a third of hospitals had functioning sterilisation equipment and 75% of the medical equipment in health facilities was more than 10 years old. In 2000, the average doctor was paid a salary of €130 a month and nurses €90, compared with the national average monthly salary of €176, according to the World Bank. Health workers routinely accepted on the side informal payments from patients and supplemented their income with private practices. Patients had to buy their own hospital supplies outof-pocket, even for items such as bandages and catheters. The goal of the government’s health reform, says Simic, has been to “build on the good points of the old system”—in particular the primarycare networks—but to shift away from a longstanding emphasis on curative medicine to an emphasis on health promotion, prevention, and screening. Some progress has been made. To improve morale and working conditions, salaries have increased by 40% and buildings are being refurbished and re-equipped. To improve effi ciency and quality, a “patient-centred focus” is being emphasised. Patients now are asked to fi ll out questionnaires about their care. In addition, the Ministry has established a reporting system to monitor such indicators as hospital mortality rates, average length of stay, and use of health services. Simic says clinics have become very competitive in their eff orts to improve their rankings. Under new payment systems, funds will no longer automatically go to providers as they did in the old system but will “follow the patients”, Simic says. “We are going to pay on the basis of how many patients a doctor sees and the quality of their care.” Last month’s national elections will bring in a new government, so Simic will be leaving the ministry this month to return to teaching, though she may continue to serve as a special adviser. One lesson she says she has learned from her 4 years at the Ministry is that while diff erent sectors can work together to improve health services, “management and coordination at the national level is the condition sine qua non for health reform”.